Situation Awareness Facilitating Excellent Care: A Human Factors Intervention to Reduce Risk in Primary Care of the Elderly
Overview: This project uses a human factors engineering intervention to increase situation awareness about primary care visits for the elderly. The intervention intends to increase physician situation awareness, reduce mental workload, and improve patient outcomes.
Ambulatory primary care is hazardous; elderly patients are even more vulnerable. Little is known about what causes various safety problems. In a previous AHRQ-funded grant, we found that nearly all safety hazards are related to information chaos (overload), under-load, scatter, conflict, and/or erroneous information. This project tests an intervention to control those hazards.
Methods: Participators include four primary care physicians each, from four clinics (16 physicians). Patients aged 65 years or older were eligible. 755 patient visits (48 per physician) were studied pre-intervention to assess care-as-usual. 1515 patient visits were randomly assigned to care-as-usual or the intervention during the intervention phase.
The “patient overview process” intervention had 3 components:
- nurse calls a patient pre-visit to collect standardized data on the patient overview document (POD) for the visit;
- nurse and physician huddle before the visit to review the POD; and finally
- physician uses the POD during the visit.
Outcome assessments included physician surveys pre- and post-visit, patient surveys post-visit, assessment of the number and types of problems per visit, visit billing data, observations of intervention and control visits, patient interviews, and staff interviews.
Tosha Wetterneck, MD, MS
Associate Professor of Medicine
School of Medicine and Public Health
University of Wisconsin-Madison
Ben-Tzion Karsh, PhD
Department of Industrial and Systems Engineering
University of Wisconsin-Madison
Brian Arndt, MD
Department of Family Medicine,
School of Medicine and Public Health
University of Wisconsin-Madison
Steve Baran, MS
Graduate assistant
Department of Industrial and Systems Engineering
University of Wisconsin-Madison
John Beasley, MD
Professor of Family of Medicine
School of Medicine and Public Health
University of Wisconsin-Madison
Vicki Bier, PhD
Professor and Chair of Industrial and Systems Engineering
University of Wisconsin-Madison
Melody Bockenfeld, MPH, BSN
Wisconsin Research Education Network
School of Medicine and Public Health
University of Wisconsin-Madison
Roger Brown, PhD
Professor, School of Nursing
Director, Research Design Methodology and Statistics Unit
University of Wisconsin-Madison
Pascale Carayon, PhD
Procter & Gamble Bascom Professor in Total Quality
Department of Industrial and Systems Engineering
Director, Center for Quality and Productivity Improvement
University of Wisconsin-Madison
Sue Dovey, PhD
Consultant
Mary Ellen Hagenauer, BA
Project Manager
Department of Industrial and Systems Engineering
University of Wisconsin – Madison
Kate Judge, MSSW
Research Specialist
Wisconsin Research Education Network
School of Medicine and Public Health
University of Wisconsin-Madison
Hannah Louks, BS
Research Coordinator
Wisconsin Research Education Network
School of Medicine and Public Health
University of Wisconsin-Madison
Peggy O’Halloran, MPH
Wisconsin Research Education Network
School of Medicine and Public Health
University of Wisconsin-Madison
Eduardo Salas, PhD
Consultant
Paul D. Smith, MD
Department of Family of Medicine
Associate Director of the Wisconsin Research Education Network
University of Wisconsin School of Medicine and Public Health
University of Wisconsin-Madison
Jamie Stone, MS
Associate Researcher
School of Pharmacy
University of Wisconsin-Madison
Jon Temte, PhD, MD
Department of Family of Medicine
School of Medicine and Public Health
University of Wisconsin-Madison
2011
Beasley, J., Wetterneck, T.B., Temte, J., Lapin, J.A., Smith, P.A., Rivera-Rodriguez, A.J., & Karsh, B.-T. (2011). Information chaos in primary care: Implications for physician performance and patient safety. The Journal of the American Board of Family Medicine 24 (6), 745-751. PMCID: PMC3286113
Lapin, J., Krueger, D., Wetterneck, T.B., Holman, G.T., Beasley, J., & Karsh, B.-T. (2011). The myth of primary care workflow. Paper presented at the Primary Care Work-life to Wellness: Engineering Quality, Safety, and Satisfaction,Wisconsin Dells, WI.
Wetterneck, T.B., Lapin, J., Krueger, D., Homan, G., Beasley, J., & Karsh, B-T. (2011). Development of a primary care physician task list to evaluate clinic visit workflow. British Medical Journal: Quality & Safety, 21 (1), 47-53. PMCID: PMC3568931
Wetterneck, T.B., Lapin, J., Beasley, J., Smith, P., & Karsh, B.-T. (2011). Please, can I have one visit where I have all the information I need? Paper presented at the 2011 Wisconsin Health Improvement and Research Partnership Forum,Madison, WI.
Wetterneck, T.B. & Holman, G.T. (2011). Use of tandem observations in ambulatory primary care to evaluate physician.Paper presented at the 3rd International Conference Healthcare Systems Ergonomics and Patient Safety Conference,Oviedo, Spain.
Wetterneck, T.B. & Holman, G.T. (2011). Failures and recovery. Paper presented at the Wisconsin Health Improvement and Research Partnerships Forum, Madison, WI.
Wetterneck, T.B. (2011). Hazards & information chaos in the primary care of the elderly. Department of Family Medicine Statewide Research Forum.
2010
Lapin, J., Krueger, D., Wetterneck, T.B., Holman, G.T., Beasley, J., & Karsh, B.-T. (2010). Workflow Schmerkflow. Paper presented at the Wisconsin Primary Care Research and Quality Improvement Forum, Middleton, WI.
Lapin, J., Krueger, D., Wetterneck, T.B., Holman, G.T., Beasley, J., & Karsh, B.-T. (2010). Quality improvement from a human factors perspective. Paper presented at the Harvard Medical School: Update in Medicine Conference, Boston, MA.
Lapin, J., Beasley, J., Smith, P., Hagenauer, M.E., & Karsh, B.-T. (2010). Hazards in the primary care of elderly patients: A qualitative analysis of physician hazard reports. Paper presented at the Family Medicine 40th Anniversary Celebration, Madison, WI.
2009
Wetterneck, T.B. & Holman, G.T. (2009). Medication information management and error recovery in primary care clinics.Paper presented at the Wisconsin Primary Care Research and Quality Improvement Forum, Madison, WI.
Our previous work showed that many of the problems in the care of elderly patients are due to physicians having inadequate or confusing information during the visit. The purpose of the SAFE-C study was to see if a simple intervention, the use of the patient overview document (POD), and a team huddle, would provide physicians with the information they need at the time that they need it. The results could make visits more efficient, effective, and safer for patients, and more satisfying for everybody.
Goals of the Patient Overview process:
- to provide the care team (the physician and his/her nurse/MA) with all of the information they need for the patient’s visit,
- to bring the care team’s attention to things they need to address during the visit, and
- to improve patient care while reducing physician workload.
We think the Patient Overview process will:
- allow the care team to plan for the visit and address the patient’s issues more efficiently at the visit rather than scrambling during and after the visit to obtain needed information,
- allow the physician and the patient to set the agenda for the visit,
- address the patient’s immediate needs as well as the patient’s ongoing medical status, for example, managing his/her chronic medical problems, and
- address preventive health needs.
The Patient Overview process: 3 Components
1. Pre-visit care coordination using the Patient Overview Document(POD). The nurse/MA will:
- review the patient record to understand the patient’s care needs and anything that has happened since the last visit,
- call the patient to complete the Patient Overview Document, and
- obtain additional information relevant to the patient visit that is not already available.
2. Care team huddle. The nurse/MA and physician will:
- review the completed POD together on the day of the patient visit (beginning of the clinic session) and
- obtain any additional needed information.
3. Use of the Patient Overview Document during the patient visit:
- the doctor will have the POD and any additional information collected for use during and after the patient visit and
- the POD can be retained in the patient chart if the doctor or the clinic decides to do this.
Note: The Patient Overview process is NOT meant to replace the medical record or the patient/doctor interaction during the appointment although you and your physician may use it to document the patient visit. Its purpose is to help guide the patient/doctor interaction to make it easier for them to focus on the most important things and to assure that all needed information is readily available at the time of the visit.
Collateral Material
The following materials were created for the SAFE-C study. The SAFE-C Research Group grants permission to use the Patient Overview Process with credit to the SAFE-C Research Group.
Training Materials
Instructions for Nurses and MAs
Patient Scenarios to be used during training sessions
Physician Overview of the Patient Overview Process
Teamwork-Huddle Training
Training Evaluation
Forms Used for Patient Overview Process
Patient Overview Document
Patient Overview Document with Sample Questions and Cues